Job Details

Director, Fraud Detection & Prevention page is loaded## Director, Fraud Detection & Preventionlocations: MO-Lake Saint Louis: MO - St. Louis - 635: MO - St. Louis - 1238time type: Full timeposted on: Posted Todayjob requisition id: REQ12963The **Director, Fraud Detection & Prevention** plays a critical leadership role in driving the organization's strategy to identify, mitigate, and address instances of fraud, inefficiency, and abuse. This position leads the Special Investigations Unit (SIU), oversees high-level investigations, and ensures adherence to all applicable federal and state regulations, including those governing Medicare and Medicaid programs.**Location: Must reside in the St. Louis, MO area. This is a hybrid role of work from home and in office work at our Lake St. Louis, MO office location.****What you'll do:*** Develop and implement a comprehensive FWA prevention and detection program across the organization* Lead investigations into suspected fraud, waste, or abuse, ensuring timely resolution and appropriate corrective actions* Draft, revise, and enforce FWA-related policies and procedures* Design and deliver targeted training programs for high-risk departments and roles* Develop dashboards and KPIs to monitor FWA trends and program effectiveness* Leverage predictive analytics, AI tools, and forensic software to proactively detect anomalies and suspicious patterns* Establish and maintain reporting mechanisms for suspected FWA, including anonymous hotlines and digital platforms* Monitor industry trends, regulatory changes, and geopolitical risks that may impact FWA exposure* Conduct risk assessments and data analytics to identify patterns and vulnerabilities* Oversee training and awareness programs to educate employees on FWA policies and ethical conduct* Prepare detailed reports for executive leadership* Ensure compliance with federal, state, and industry-specific regulations (e.g., HIPAA, CMS, DOJ guidelines)* Monitor emerging threats and trends in fraud and abuse, adapting strategies accordingly* Other duties as assigned**What you'll need:*****Experience, Education & Certifications:**** Bachelor's degree required, preferably in a business-related field* 7–10 years of experience in healthcare fraud investigations or regulatory compliance* Experience with case management systems, forensic tools, and data analytics platforms* Experience managing cross-functional teams and external audits***Skills:**** Excellent organizational skills* Ability to multi-task and set priorities in a fast-paced environment* Ability to handle confidential information in a professional manner* Ability to make solid judgment calls* Conduct all activities in an organized, timely and responsible manner* Ability to gain and maintain knowledge of all department responsibilities preferred* Proficiency with MS Office Suite* Demonstrate excellent time management skills* Ability to work within a team-oriented environment* Ability to identify, interpret and communicate business risks* Ability to lead, coach and motivate a specialized compliance team* Detail oriented, with excellent communication skills* Data analysis and interpretation skills* Ability to schedule, organize and prioritize multiple tasks* Excellent problem-solving skills with the ability to anticipate and resolve problems* Ability to maintain positive attitude and team focused during high stress situations* Ability to maintain high level of confidentiality* Strong understanding of Medicare, Medicaid, and commercial insurance programs* Familiarity with whistleblower protections and internal control* Deep understanding of regulatory frameworks and enforcement mechanisms**Even better if you have...*** Master's degree in a related field a plus* Professional certifications such as CFE (Certified Fraud Examiner), CIA, or similar strongly preferred**What's in it for you:*** Health and Life Insurance Plans* Dental and Vision Plans* 401(k) with a company match* Paid Time Off and Holiday Pay* Maternity/Paternity Leave* Casual Dress Environment* Tuition Reimbursement* MTM Perks Discount Program* Leadership Mentoring Opportunities***Equal Opportunity Employer: MTM is an equal opportunity employer. MTM considers qualified candidates with a criminal history in a manner consistent with the requirements of applicable local, State, and Federal law. If you are in need of accommodations, please contact MTM's People & Culture.***#MTM#J-18808-Ljbffr